Semantic search
| Entered date | Event description | |
|---|---|---|
| ENS 50643 | 26 November 2014 14:54:00 | Per 10 CFR 20.1906(d), (licensee is) reporting receipt of a package of radioactive material with removable surface contamination on the outside of the package greater than NRC reporting limits. The package was received today (November 26, 2014) at around 0800 PST by VA Central California Health Care System. This facility holds permit number 04-01935-03 under the VHA (Veterans Health Administration) master materials license. The package was checked-in and surveyed around 0830 PST. Wipe tests performed on the external surface of the package indicated a removable contamination level of 7155 dpm/cm2 as compared to the regulatory limit of 220 dpm/cm2 for beta-gamma emitters. The package contained seven unit dosages of radiopharmaceuticals ranging between 10 and 40 millicuries each of Technetium-99m and was shipped from Cardinal Health in Fresno, California. The specific radionuclide that resulted in the contamination was not identified but does not appear to be Technetium-99m. The wipe counting statistics were based on Ba-133. The inner packaging materials were not contaminated. The facility immediately notified the vendor/shipper, who serves as the final delivery carrier, about the contaminated package at about 0835 PST. VHA National Health Physics Program was notified around 0845 PST with initial information. As corrective actions, the packaging materials were bagged and set aside in a restricted area at the facility for further evaluation." The licensee notified the NRC Region III Project Manager (Null). |
| ENS 43917 | 18 January 2008 15:20:00 | The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Boston Healthcare System, Boston, Massachusetts. The possible medical event occurred on January 17, 2008, and was discovered the same day. The basis for the possible medical event is under 10 CFR 35.3045(a)(2) and involved administration of radiopharmaceutical that might have resulted in more than 50 rem to tissue and involved a wrong route of administration. Specifically, a F-18 FDG injection of approximately 3.6 millicuries was infiltrated into a patient's arm. The Department of Veterans Affairs and permittee are reviewing the possible medical event circumstances and the dose calculation methods. The permittee informed the patient and referring physician.
The basis for retracting the event is that infiltration is not considered to be a wrong route of administration. This basis was communicated to NHPP (National Health Physics Program) in a phone call received from our NRC Region III Project Manager (Cassandra Frazier) on March 7, 2008 at 4:40 pm. Notified R1DO (Lorson), R3DO (Ring), and FSME (Burgess). |
| ENS 43265 | 29 March 2007 12:48:00 | The possible medical event occurred at a broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Eastern Colorado Health Care System, Denver, Colorado. The possible medical event occurred on May 31, 2006. The possible medical event was discovered on March 28, 2007. The basis for the possible medical event is under 10 CFR 35.3045(a)(1)(i) and involved administration of a dose different from the dose prescribed in the written directive. Specifically, the written directive for a patient therapy procedure listed the dose to be 15 millicuries Iodine 131 when in fact 30 millicuries was given to the patient. Since the clinical intent was for the patient to receive 30 millicuries, the possible medical event will not have any adverse impact on the patient. The permittee has implemented corrective actions to prevent a recurrence of the circumstances that resulted in the possible medical event. The Department of Veterans Affairs will evaluate the circumstances related to the possible medical event and submit a written report to NRC, Region III, within 15 days.
This event has been reviewed and determined to be a reportable medical event. A "Medical Event" may indicate potential problems in a medical facility's use of radioactive materials. It does not necessarily result in harm to the patient. |
| ENS 42485 | 10 April 2006 13:54:00 | My name is Gary Williams with the Department of Veterans Affairs, National Health Physics Program (NHPP). I am calling to report a loss of radioactive materials. The loss occurred at a medical permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-2385301VA. The permittee is the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. The loss occurred in 2005 and was discovered in April 2006. The basis for the report is under 10 CFR 31.5(c)(10) in that radioactive materials obtained under a general license were lost and the reporting requirements in 10 CFR 20.2201 must be followed. Specifically, the permittee stated one tritium exit sign was apparently disposed or discarded during a facility construction project in 2005. The sign was last seen in 2004. The sign was either of two models. The first model is a 11.5 Curie sign from Shield Source Incorporated. The second model is a 20 Curie sign from SRB Technology. These types of signs were manufactured circa 1994. The Department of Veterans Affairs will evaluate the circumstances related to the loss of radioactive materials and submit a written report to NRC, Region III, within 30 days. HOO NOTE: The Department of Veterans Affairs coordinates all reports to the NRC from their NHPP Director's Office located in Little Rock, AR. NRC oversight for the VA Master Materials licensee is assigned to NRC Region III. THIS MATERIAL EVENT CONTAINS A "LESS THAN CAT 3" LEVEL OF RADIOACTIVE MATERIAL Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. |
| ENS 42117 | 4 November 2005 09:14:00 | I am calling per 10 CFR 20.2201(a)(ii) to notify you of a possible loss of radioactive material at the VA Medical Center, New Orleans, Louisiana, a permittee under the VA license. This incident occurred on or around August 30, 2005, and was discovered October 7, 2005. This possible incident resulted from the flooding of the radioactive waste storage room at the medical center and involved the loss of radioactive materials. The materials which are considered lost are Iodine 131 and Iodine 125. The unsealed materials were in waste containers and may have washed out of the containers when the waste room was flooded. The dilution of the small amount of activity in the floodwaters precludes any possible public dose or health and safety concern. These circumstances are considered a possible incident since a technical evaluation to estimate the loss is not based on quantitative measurements or surveys. Also, the tags and waste records attached to the containers were obliterated by the floodwaters. Attempts to estimate the activity began on October 7, 2005, and an estimate of the original activity was submitted by the permittee in a preliminary report to the National Health Physics Program on October 24, 2005. A best estimate based on review of storage records, radioactive decay, and observations and measurements in the waste room is that, perhaps, as much as 200 microcuries Iodine 131 and 600 microcuries Iodine 125 in storage August 30, 2005, cannot be specifically located or identified as being present in the waste storage room on October 7, 2005. Sources that are "Less than IAEA Category 3 sources," are either sources that are very unlikely to cause permanent injury to individuals or contain a very small amount of radioactive material that would not cause any permanent injury. Some of these sources, such as moisture density gauges or thickness gauges that are Category 4, the amount of unshielded radioactive material, if not safely managed or securely protected, could possibly - although it is unlikely - temporarily injure someone who handled it or were otherwise in contact with it, or who were close to it for a period of many weeks. |
| ENS 41443 | 25 February 2005 12:18:00 | The following information was provide by the licensee via facsimile: (The Department of Veteran Affairs National Health Physics Program called) per 10 CFR 35.3045 to notify (the NRC) of a possible medical event at the VA Medical Center, Durham, North Carolina, a permittee under the VA license. This event was discovered on February 25, 2005. On February 24, 2005, a permanent-implant prostate brachytherapy procedure was performed at the medical center. 84 Iodine-125 seeds were implanted in the patient. These seeds had around 400 microcuries per seed. A number of seeds were mistakenly placed in fatty tissue, outside of the intended area of treatment. Based on a preliminary evaluation, a possible medical event occurred since the dose to the prostate was possibly more than 20 percent less than that prescribed and a dose to tissue other than the treatment site is possibly more than 50 rem and greater than 50% of the prescribed dose. The authorized user notified the patient and will notify the referring physician within 24-hours of discovery. The National Health Physics Program intends to conduct a reactive inspection next week. |
| ENS 41203 | 17 November 2004 15:22:00 | Department of Veterans Affairs, National Health Physics Program report the following information: I am calling to report packages that exceeded the limits for removable radioactive surface contamination. The packages were received between 0700 to 1200, November 17, 2004, by the permittee (VA Medical Center, Salem, Virginia) authorized under the master license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The basis for reporting the loss is under 10 CFR 20.1906(d)(1) in that the packages, ammo boxes being used to deliver radioactive materials, had approximately 28, 70, and 110 DPM per centimeter squared removable radioactive contamination on the outside. The contamination was identified as Technetium-99M. The Cardinal Health Nuclear Pharmacy Services delivered the packages. The status of whether the vendor delivery vehicle was exclusive use was not determined. The permittee Radiation Safety Officer notified the vendor about the package and has taken appropriate health and safety steps to prevent any possible spread of contamination. |
| ENS 41153 | 27 October 2004 18:16:00 | RSO for the VA Medical Center, New Orleans, LA was notified at 0900 CDT on 10/27/04 of a missing shipment of I-125 (10 millicuries) that had been received by that facility on 10/26/04. The RSO is conducting an investigation into the missing radioactive material.
The radioactive material was I-125 as sodium iodide, liquid form, shipped in a shielded vial containing 10 millicuries in a volume of less than 1 milliliter. The RAM was to be used in a biomedical research lab. The permittee investigated the loss and concluded the radioactive material most likely ended up in a local landfill. The permittee notified the local landfill operations staff of the event. The permittee and landfill operations staff performed radiation surveys of the landfill. The radiation surveys did not locate the missing radioactive material. The NHPP performed a reactive inspection one week after the loss was discovered. The initial inspection results confirm the radioactive material is most likely buried at the local landfill and is not recoverable. According to witnesses, the probable cause of the event is the shipping box was not correctly labeled as containing radioactivity. Notified NMSS (Moore), R3DO (Ring), and R4DO (Gody). |
| ENS 41044 | 16 September 2004 13:57:00 | The Department of Veterans Affairs, National Health Physics Program reported a package that exceeded the limits for removable radioactive surface contamination. The package was received on September 16, 2004, by a permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is the Clement J. Zablocki VA Medical Center, Milwaukee, Wisconsin. This event is reported under 10 CFR 20.1906(d)(1) in that the package, an ammo box being used to deliver radioactive materials, had approximately 11,000 disintegrations per minute per square centimeter removable radioactive contamination on the outside. The contamination was limited to one small spot on the ammo box exterior. The interior of the box was not contaminated. The contamination was identified as 99M-Tc. The Cardinal Health Nuclear Pharmacy Services delivered the package. The permittee Radiation Safety Officer notified the vendor about the package. There was no personnel contamination involved. |
| ENS 40729 | 6 May 2004 14:47:00 | The following information was obtained from the Master Materials License Holder via facsimile: The loss occurred at a medical permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853 01 VA. The permittee is the Clement T. Zablocki VA Medical Center, Milwaukee, Wisconsin. The loss occurred circa 2001 and was discovered on May 6, 2004. The basis for the report is under 10 CFR 31.5(c)(10) in that radioactive materials obtained under a general license were lost and the reporting requirements in 10 CFR 20.2201 must be followed. Specifically, the permittee stated four tritium exit signs were apparently disposed or discarded during a facility construction project circa 2001. The signs were last seen in 2000. The signs were either of two models. 'The first model is a 11.5 Curie sign from Shield Source Incorporated. The second model is a 20 Curie sign from SRB Technology. The signs were manufactured circa 1994. The Department of Veterans Affairs will evaluate the circumstances related to the loss of radioactive materials and submit a written report to NRC, Region III, within 30 days. |
| ENS 40690 | 21 April 2004 12:15:00 | A package that exceeded the limits for removable radioactive surface contamination was received April 21, 2004, by VA Chicago Health Care System , a permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The basis for reporting the contamination is under 10 CFR 20.1906(d)(1) in that the package, an ammo box being used to deliver radioactive materials, had approximately 80.9 disintegrations per minute per square centimeter removable radioactive contamination on the outside. The contamination was identified as Tc 99M. The Cardinal Health Nuclear Pharmacy Services delivered the package. The status of whether the vendor delivery vehicle was exclusive use was not determined. The ammo box has been decontaminated. The permittee's Radiation Safety Officer notified the delivery vendor about the package. |
| ENS 40578 | 9 March 2004 13:06:00 | The Department of Veterans Affairs reported the following via facsimile: I am calling to report a loss of licensed material. The loss occurred at a medical broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Boston Healthcare System, Boston, Massachusetts. The loss was reported to the permittee Radiation Safety Officer on March 8, 2004. The basis for reporting the loss is under 10 CFR 20.2201(a)(i) in that a waste vendor reported that a drum from the permittee triggered a radiation detector at a landfill. The activity involved although unknown at this time could potentially be greater than the reporting limit. Specifically, the vendor (New York Environmental Services) indicated that a survey meter reading on contact with the drum was 4.8 millirem per hour. The drum is being returned to the permittee for radionuclide evaluation. The Department of Veterans Affairs will evaluate the circumstances related to the loss and submit a written report to NRC, Region III, within 30 days.
The following retraction was faxed to the NRC Operations Center on 3/31/04. Categorization of this information as a retraction was reviewed and approved by K. O'Brien, NRC Region 3. The licensed material was recovered and returned to the VA Boston Healthcare System for evaluation on March 11, 2004. The medical center RSO evaluated the drum contents for radionuclidic identity and activity. The National Health Physics Program (NHPP) performed an inspection at the Medical Center on March 18, 2004. The NHPP inspection included a review of the Medical Center RSO's analysis of the recovered. Licensed material. Analysis of the recovered drum indicated a total activity of less than 100 (microcuries) of I-125, (less than 1000 times Appendix C, 10 CFR 20) reportable quantity specified by 10 CFR 20.2201(a)(i). Since the material was recovered and is in the possession of permittee, a 30-day report specified by 10 CFR 20.2201(a)(ii) is not required. Notified NMSS EO (C. Miller), R1DO (K. Jenison), |
| ENS 40490 | 30 January 2004 13:26:00 | The medical event occurred at a medical broad-scope permittee authorized under the master materials license issued to the Department of Veterans Affairs, NRC License 03-23853-01VA. The permittee is VA Boston Healthcare System, Boston, Massachusetts. The medical event occurred on January 29, 2004, and was discovered the same day. The basis for the medical event is under 10 CFR 35.3045(a)(1)(ii) in that an administered dosage differed from the prescribed dosage by more than 20% and resulted in a dose of more than 50 rem to an organ. Specifically, the verbal order from the authorized user was for 5 microcuries Iodine 131 and the patient was given 500 microcuries Iodine 131. After the event was discovered, the patient was given a thyroid blocking solution. Based on the patient's resultant thyroid uptake, the permittee computed a dose to the thyroid of approximately 83 rem. The authorized user does not anticipate any adverse medical effects to the patient. The permittee has implemented initial corrective actions to prevent a recurrence of the circumstances that resulted in the medical event. The Department of Veterans Affairs will evaluate the circumstances related to the medical event and submit a written report to NRC, Region III, within 15 days. |